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Strongyloides The ARDS Executive has asked ARDS to make Strongyloides a high priority project because literally thousands of Aboriginal people in Australia are living with Strongyloides. There are reliable tests and treatment for these potentially lethal parasitic worms called Strongyloides stercoralis.
This page has a wide variety of information and includes links to original research papers and reviews about Strongyloides. Info LinksStrongyloides Flip Chart Story for patients (607kb) Articles on which this information is based are available for download from this web site subject to COPYRIGHT CONDITIONS as follows: Visitors may not reproduce, retransmit, publish or otherwise exploit the work. Visitors are permitted to make hard copies of the work for the purpose of private research and study only. Affects Aboriginal PeopleStrongyloides are found in many parts of the world including Aboriginal tropical northern Australia.Strongyloides stercoralis are tiny parasitic worms that infect many Aboriginal people who live in tropical Australia 1,2,3,4,5,6. The infective worms are found in or near faeces from infected people. When the infective worms get on to the skin, they burrow through the skin and cause a disease called strongyloidiasis 7. This disease can be diagnosed and cured 8, but because its symptoms mimic those of other diseases, strongyloidiasis is often not recognized. A person with Strongyloides whose immunity is impaired is in danger of dying 9,10,11,12,13,14. Under those circumstances, the worms multiply rapidly, invade any part of the body and overwhelm the patient 7,10.Secondary bacterial infection increases the intensity of the illness 13,14,15. If such patients are not promptly diagnosed correctly and given the specific treatment for Strongyloides, they die 14. Strongyloides also affects refugees and immigrants from parts of the world where the disease is endemic 16,17,18, and ex-servicemen and others who have spent time in these areas of endemicity 19,20. A disease for lifePeople with Strongyloides remain infected for life unless they get treatment that eliminates all the worms.
People with Strongyloides have the worms until they die, unless they receive effective treatment. Typically, people with Chronic Strongyloidiasis have the disease for decades before being diagnosed and treated 19,20. Their immune system keeps the worms in check but never eliminates the worms 16,17. The adult worms are stunted and their reproductive rate is slow 7. Deaths from corticosteroidsTreatment with corticosteroids precipitates severe strongyloidiasis and death unless the patient receives effective treatment in time 10. 60% of deaths due to strongyloidiasis are caused by the administration of corticosteroid drugs to patients with chronic strongyloidiasis 10,14. When these drugs are present in the body, the adult worms recover and multiply out of control. Other conditions which depress the immune system also lead to severe strongyloidiasis and death if not successfully treated 4. These conditions include malnutrition 9 and HTLV-1 infection 21,22. The duration of the final illness varies from 1 to 90 days with a mean of 14 days.1 Corticosteroids are sometimes given to patients for respiratory symptoms due to migrating larvae. 10,18 TransmissionStrongyloides spread when a person comes into contact with infective worms in or near faeces from a person with Strongyloides. People get Strongyloides when immature infective Strongyloides touch the skin and enter the body through the skin. The infective Strongyloides are present in or near faeces from a person with Strongyloides 7. The infective Strongyloides live outside the body for a short time, a few hours or a few days 23. People who live in the same household as someone with Strongyloides are more likely to have the disease than their neighbours 24. Life CycleStrongyloides cycle through the body and the soil and also multiply inside people.Inside the body, Strongyloides migrate through the tissues until they reach the small intestine. They burrow into the mucosa where they lay embryonated eggs. The eggs hatch quickly, and the larvae escape into the lumen of the small intestine. Some pass out of the body with the faeces, others develop quickly and penetrate the body through the side of the lower intestine, and migrate through the tissues until they reach the small intestine where they also become adults and reproduce. In this way Strongyloides multiply in the body 7. Some of the larvae leave the body with the faeces. Some become infective very quickly, others become adult and complete a single generation in the soil 25. Then they can only reproduce again when they enter another person through the skin. Strongyloides in the soil are killed by heat, cold or dry conditions. They usually live for a few hours or a few days 23. Under the best conditions, they may survive for about 15 days 7.
Secondary InfectionStrongyloidiasis is frequently accompanied by secondary infection by gut bacteria.When Strongyloides multiply in the body, the infective larvae carry gut bacteria with them into the body when they enter the body through the side of the lower gut, and they take the bacteria with them to any part of the body 15. The bacteria may cause pneumonia, meningitis or septicaemia 13,14,15, or abscesses in the liver or kidneys. Infections in many parts of the body with species of bacteria that normally live in the gut may indicate an underlying infection with Strongyloides 14.
Symptoms are Non-SpecificSymptoms of Strongyloides often mimic other diseases.Abdominal pain and diarrhoea, itchy skin rashes, respiratory symptoms are common symptoms of chronic strongyloidiasis. These same symptoms in a more severe form and shock are common symptoms of severe Strongyloides disease (Acute Strongyloidiasis and Disseminated Strongyloidiasis or Hyperinfection) 13,14. Strongyloides may cause symptoms in many parts of the body 13,14. The only symptom that is found only in Strongyloidiasis is larva currens, a raised rash that moves randomly across the skin typically at about 2 cm in an hour 13.
TestsStrongyloides is usually diagnosed by a blood test or a faecal test.For those people with chronic Strongyloides disease a simple blood test will tell whether they have Strongyloides. The blood test is for specific IgG antibodies to Strongyloides. A positive test indicates current infection 8, not a past infection. Stool tests are very insensitive for chronic strongyloidiasis 26,27. People who acquired Strongyloides recently 28 people with HTLV-1 infection, and people with severe disease may not have the antibodies 7, 22. Their faeces should be examined for Strongyloides using the agar plate test 7, 27. A positive value from any one test indicates Strongyloides. TreatmentIvermectin is a safe drug 29,30 and the most effective drug available for Strongyloides.Ivermectin 0.2mg/kg is the most effective drug. It cures about 80% of patients 31. Albendazole 400mg for 3 days, the standard treatment cures only about 40% of patients 31. When Albendazole is given twice daily for 3 days it is 75% effective 33. Two courses of treatment are more effective that one 8. All the worms must be killed by the treatment, or the remainder will multiply again in the body and reestablish the patent infection 7,32.
Defining CureCriterion for cure is negative blood test, negative stool test and no symptoms, all three 33.The serum of a person who has been cured becomes negative by 6 months after treatment. If the test is positive, they still have Strongyloides and must be treated again. The process must be repeated until the test is negative and the person has no symptoms. 8 Even if the test is negative, if symptoms persist, the person needs retreatment 33. If repeated treatment does not kill all the worms, the person must be treated periodically so that only a few worms remain in the body 21.
Reservoir is humanInfected people are the reservoir for Strongyloides infection. Mass treatment by ivermectin is likely to markedly reduce transmission.Strongyloidiasis is a preventable disease. Where there is a good water supply and sanitation and good hygienic practices, there is no transmission of the disease 20. People are the reservoir for Strongyloides. Strongyloides live for only a short time outside the body 23. If Strongyloides worms are eliminated from everyone in a community at the same time during the dry season, there is a good chance of eliminating it from that group of people 5. Vigilance should be exercised because infected visitors could reestablish Strongyloides in the community.
CostCost of StrongyloidiasisMost of the cost of Strongyloidiasis is borne by the individual sufferer in the form of chronic ill health, loss of earnings, cost and pain of medical investigations, and the psychological pain that is caused by medical practitioners who do not believe their symptoms are real. There are also hidden costs to the health system as sufferers unsuccessfully seek a diagnosis of their illness. This can include the considerable cost of evacuation of patients from remote communities and the cost of treatment in intensive care for those with the severe form of the disease 34. Additional information Strongyloides stercoralis endemicity in Australia includes subtropical as well as tropical regions. It occurs in Northern New South Wales in the Northern Rivers region 35, in Central Australia where it coexists with HTLV-1 that affects 12% of the Indigenous population. 36 The response of Strongyloides to various drugs varies.38 There is dose-dependent eradication of adult worms and larvae and surviving larvae do not mature with Ivermectin. Albendazole also causes dose-dependent eradication of adults in the gut and larvae in the tissues, but Ivermectin is more effective. Cambendazole eliminates adults and larvae. Mebendazole kills adults but not larvae, but is between 100 and 1000 times less effective than Cambendazole. Thiabendazole was previously believed to be effective, but it does not kill the adult worms. It reduces larval output and has no effect on larvae in the tissues. Further evidence of the use of repeat IgG serology after 6 months to check for cure has been obtained from a treatment study in Central Queensland.39 References1. Flannery G and White N. (417kb) Immunological parameters in northeast Arnhem Land Aborigines: consequences of changing settlement patterns and lifestyles. In: Laurence M Schell, Malcolm T Smith and Alan Bilsborough, eds: Urban Ecology and Health in the Third World. 32nd Symposium Volume of the Society of the Study of Human Biology, 1993, pp202-220. Cambridge: Cambridge University Press. ©Copyright 1993, Cambridge University Press – reproduced with permission. Link to Cambridge University Press http://www.cambridge.org/aus/catalogue/catalogue.asp?isbn=9780521411592 2. Aland K. (102kb) Worm project at Galiwin’ku. Working Together, 1996, 6 (6) 10. ©Copyright -reproduced with permission of the author. 3. Van Ingen I. (140kb) Strongyloidiasis in an island community. Progress of a treatment programme. Second National Strongyloidiasis Workshop, Brisbane 2003, URL. www.jcu.edu.au/school/phtm/PHTM/ss/ ©Copyright – reproduced with permission of the author. 4. Page WA, Dempsey K (294kb) Report on Miwatj Strongyloidiasis Study. Implementing best practice in the eradication of chronic strongyloidiasis for clients of Miwatj Health Aboriginal Corporation 2004. ©Copyright – reproduced with permission of the author. 5. Prociv P, Luke R.(616kb) Observations on strongyloidiasis in Queensland Aboriginal communities. Medical Journal of Australia 1993, 158: 160-163. ©Copyright 1993, The Medical Journal of Australia - reproduced with permission. 6. Sampson I, Smith DW, McKenzie B.(716kb) Serological diagnosis of Strongyloides stercoralis infection. Second National Strongyloidiasis Workshop Brisbane July 2003, URL. www.jcu.edu.au/school/phtm/PHTM/ss/ ©Copyright – reproduced with permission of the author. 7. Speare R.(1585kb) Strongyloides stercoralis the parasite. Second National Strongyloidiasis Workshop, Brisbane 2003, URL. www.jcu.edu.au/school/phtm/PHTM/ss/ ©Copyright – reproduced with permission of the author. 8. Page WA, Dempsey K, McCarthy JS.(231) Utility of serological follow-up of chronic strongyloidiasis after anthelminthic chemotherapy. Transactions of the Royal Society of Tropical Medicine and Hygiene 2006, 100:1056-1062. ©Copyright 2006, The Royal Society of Tropical Medicine and Hygiene – reproduced with permission. Hypertext link to ScienceDirect Page http://www.sciencedirect.com/science/journal/00359203 9. Scowden EB Schaffner W Stone WJ.(3103kb) Overwhelming strongyloidiasis an unappreciated opportunistic infection. Medicine 1978, 57: 527-544. ©Copyright 1978. Medicine – reproduced with permission. 10. Lim L, Biggs B-A.(4550kb) Fatal disseminated strongyloidiasis in a previously treated patient. Medical Journal of Australia 2001, 174:355-356. ©Copyright 2001. The Medical Journal of Australia - reproduced with permission. 11. Hansman D.(21kb) Public Health Information. A Rapidly Progressive Fatal Illness Associated with Strongyloidiasis. Communicable Disease Report, Women’s and Children’s Hospital, Adelaide 1995. Phone 0881616725, Department of Microbiology and Infectious Diseases. ©Copyright 1995 Women’s and Children’s Hospital – reproduced with permission.
12. Byard RW, Bourne AJ, Matthews N, Henning P, Robertson DM, Goldswater PN, Hansman D. (2990kb) Pulmonary strongyloidiasis in a child diagnosed on open lung biopsy. Surgical Pathology 1993, 5(1):55-62. Reproduced with permission of the author. 13. Grove DI.(1246kb) Clinical Manifestations. In: DI Grove (ed) Strongyloidiasis an important roundworm infection in man. London: Taylor & Francis 1989, 155-173. ©Copyright 1989 Taylor & Francis – reproduced with permission. 14. Speare R, Durrheim D, White S.(57kb) Fatal strongyloidiasis lessons from the literature. Second National Strongyloidiasis Workshop, Brisbane 2003, URL. www.jcu.edu.au/school/phtm/PHTM/ss/ ©Copyright 2003, reproduced with permission of the author. 15. Mak DB.(382kb) Recurrent bacterial meningitis associated with strongyloides hyperinfection (Letter). Medical Journal of Australia 1993, 159: 354. ©Copyright 1993. The Medical Journal of Australia - reproduced with permission. 16. De Silva S, Saykao P, Kelly H Macintyre N Ryan J Leydon J Biggs B-A.(527kb) Chronic Strongyloides stercoralis infection in Laotian immigrants and refugees 7-20 years after resettlement in Australia. Epidemiology and Infection 2002; 128: 439-444. ©Copyright 2002, Cambridge University Press – reproduced with permission of the publisher and the senior author. 17. Rice JE, Skull SA, Pearce C, Mulholland N, Davie G, Carapetis JR.(abstract) Screening for intestinal parasites in recently arrived children from East Africa. Journal of Paediatrics and Child Health. 2003; 39: 456-9. ©Copyright 2003, Blackwell Publishing 18. Einsiedel L, Spelman D.(87kb) Strongyloides stercoralis: risks posed to immigrant patients in an Australian tertiary referral centre. Internal Medicine Journal 2006, 36: 632-637. ©Copyright 2006, Blackwell Publishing – reproduced with permission. 19. Pelletier LL, Baker CB, Gam AA, Nutman TB, Neva FA. Chronic Strongyloidiasis in World War II Far East ex-prisoners of war. American Journal of Tropical Medicine and Hygiene 1984: 33(1): 55-61.©Copyright 1984, The American Society of Tropical Medicine and Hygiene. 20. Grove DI.(1137kb) Strongyloidiasis in Allied ex prisoners of war. British Medical Journal 1981, 280: 598-601. ©Copyright 1981, British Medical Journal – reproduced with permission. 21. Satoh M, Toma H, Sato Y, Takara M, Shiroma Y, Kiyuna S, Hirayama K.(abstract) Reduced efficacy of treatment of strongyloidiasis in HTLV-1 carriers related to enhanced expression of IFN-gamma and TGF-beta1. Clinical & Experimental Immunology 2002, 127: 354-359. ©Copyright 2002 Springer Milan 22. Keiser PB Nutman TB Strongyloides stercoralis in the immunocompromised population. Clinical Microbiology Reviews 2004, 17:208-217. Link to article on Clinical Microbiology Reviews web page. http://cmr.asm.org/cgi/content/abstract/17/1/208 Follow links on web page to download the full text . 23. Galliard H.(331kb) Recherches sur l’infestation experimentale a Strongyloides stercoralis au Tonkin (1 re note). Annales de Parasitologie Humaine et Comparee 1951, 26: 201-227 (Longevity of L3i). ©Copyright Parasite Journal – Excerpt and English translation reproduced with permission. 24. Lindo JF, Robinson RD, Terry SI, Vogel P, Gam AA, Neva FA, Bundy DA. (732kb) Age-prevalence and household clustering of Strongyloides stercoralis infection in Jamaica. Parasitology 1995, 110 (1):97-102. ©Copyright 2003, Cambridge University Press – reproduced with permission of the publisher and lead author. 25. Yamada M, Matsuda S, Motokuni N, Arizono N. Species-specific differences in heterogonic development of serially transferred free-living generations of Strongyloides planiceps and Strongyloides stercoralis. Journal of Parasitology 1991, 77: 592-594. Link to first page of article. 26. Dreyer G, Fernandez-Silva E, Alves S, Rocha A, Albuquerque R, Addiss D. Patterns of detection of Strongyloides stercoralis in stool specimens: implications for diagnosis and clinical trials. Journal of Clinical Microbiology 1996, 34: 2569-2571. Link to article on Journal of Clinical Microbiology web page. 27. Conway DJ, Lindo JF, Robinson RD, Bundy DAP.(753kb) Towards effective control of Strongyloides stercoralis. Parasitology Today 1995, 11(11):421-424. Reprinted from Parasitology Today, volume 11, Conway DJ, Lindo JF, Robinson RD, Bundy DAP, Towards effective control of Strongyloides stercoralis, pages 421-424, ©Copyright (1995), with permission from Elsevier. Link to the Trends in Parasitology Homepage 28. Sudarshi S, Stumpfle R, Armstrong M, Ellman T, Parton S, Krishnan P, Chiodini P, Whitty CJM. (abstract) Clinical presentation and diagnostic sensitivity of laboratory tests for Strongyloides stercoralis in travellers compared with immigrants in a non-endemic country. Tropical Medicine and International Health 2003, 8: 728-732. ©Copyright Blackwell Publishing 29. Pacque MC, Dukuly Z, Greene BM, Munoz B, Keyvan-Larijani E, Williams PN, Taylor HR. (abstract) Community –based treatment of onchocerciasis with ivermectin: acceptability and early adverse reactions. Bulletin of the World Health Organisation 1989, 67: 723-730. 30. Pacque M, Munoz B, Poetschke G, et al. (abstract) Pregnancy outcome after inadvertent ivermectin treatment during community-based distribution. Lancet 1990, 336: 1486-1489. 31. Datry A, Hilmarsdottir I, Mayorga-Sagastume R, Lyagoubi M, Gaxotte P, Biligui S Chodakewitz J, Neu D, Danis M, Gentilini M.(506kb) Treatment of Strongyloides stercoralis infection with ivermectin compared with albendazole: results of an open study of 60 cases. Transactions of the Royal Society for Tropical Medicine and Hygiene 1994, 88: 344-345. . ©Copyright 1994, Royal Society of Tropical Medicine and Hygiene – reproduced with permission.
32. Schad GA, Thompson F, Talham G, Holt D, Nolan TJ, Ashton FT, Lange AM, Bhopale VM. (2350kb) Barren female Strongyloides stercoralis from occult chronic infections are rejuvenated by transfer to parasite-naive recipient hosts and give rise to an autoinfective burst. Journal of Parasitology 1997, 83:785-91. ©Copyright Journal of Parasitology – reproduced with permission. 33. Archibald LK, Beeching NJ, Gill GV, Bailey JW, Bell DR.(abstract) Albendazole is effective treatment for chronic strongyloidiasis. Quarterly Journal of Medicine 1993, 86 (3):191-5. 34. Speare R, Durrheim, D. Strongyloides serology – useful for diagnosis and management in rural Indigenous populations, but important gaps in knowledge remain. Rural and Remote Health 2004, 4: 264 (Online). 35. Cooper J (5.7MB Powerpoint). Strongyloides in Northern New South Wales. Fourth National Strongyloidiasis Workshop, Adelaide, 2007. URL: www.jcu.edu.au/school/phtm/PHTM/ss/4natwork/4thNatWorkshop-proceedings.htm 36. Einsiedel L (14.9MB Powerpoint) . Dangerous liaisons: HTLV-1 and Strongyloides stercoralis in Central Australia. Fourth National Strongyloidiasis Workshop, Adelaide, 2007. URL : www.jcu.edu.au/school/phtm/PHTM/ss/4natwork/4thNatWorkshop-proceedings.htm 37. Woods R. Strongyloides near Kuranda. Fourth National Strongyloidiasis Workshop, Adelaide, 2007. www.jcu.edu.au/school/phtm/PHTM/ss/4natwork/4thNatWorkshop-proceedings.htm 38. Grove (66mb Powepoint) Fifteen years research into strongyloidiasis. Fourth National Strongyloidiasis Workshop, Adelaide, 2007. URL www.jcu.edu.au/school/phtm/PHTM/ss/4natwork/4thNatWorkshop-proceedings.htmt 39. Lord R. 2005 (42kb) Antibody detection in human strongyloidiasis in an Aboriginal community. Third National Strongyloidiasis Workshop, Yeppoon 2005. www.jcu.edu.au/school/phtm/PHTM/ss/strongyloides-3rd-workshop-recommendations.pdf For further information, contact: jenny.shield@ards.com.au ARDS would like to acknowledge the support of the Nhulunbuy Rotary Club in supporting the production of this web page. Top of Page |
Message from Chairman of ARDS with video
Video and Audio of Strongyloides sufferers talking
Video of ARDS CEO Richard Trudgen talking about Strongyloides
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